Thiazide Diuretics


Article Author:
Pegah Akbari


Article Editor:
Arshia Khorasani-Zadeh


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/4/2019 4:08:04 PM

Indications

Thiazide diuretics are an FDA-approved class of drugs that inhibit reabsorption of 3% to 5% of luminal sodium in the distal convoluted tubule of the nephron. By doing so, thiazide diuretics promote natriuresis and diuresis. Three thiazide diuretics are commonly used: hydrochlorothiazide (HCTZ), chlorthalidone, and indapamide.

HCTZ and chlorthalidone are FDA-approved for clinical use in the management of primary hypertension. These agents are used as either the sole modality of treatment or in conjunction with other antihypertensive drugs to effectively increase therapeutic response in severely hypertensive patients.

HCTZ and chlorthalidone are also FDA-approved for clinical use in adjunctive therapy in edema that is associated with chronic heart failure (CHF), hepatic cirrhosis, corticosteroids, and estrogen therapy. These agents are also used to manage edema caused by various forms of renal dysfunction such as nephrotic syndrome, acute glomerulonephritis, and chronic renal failure.

Indapamide is FDA-approved for the treatment of salt and fluid retention associated with CHF, and in the management of primary hypertension as either the sole treatment or in conjunction with other antihypertensive drugs.

Thiazide diuretics are also indicated for use (although not FDA-approved) for nephrolithiasis, osteoporosis, and diabetes insipidus.[1][2]

Mechanism of Action

Thiazide diuretics exert their diuretic effect via blockage of the sodium-chloride (Na/Cl) channel in the proximal segment of the distal convoluted tubule (DCT). When the Na/Cl channel is blocked, decreased levels of sodium cross the luminal membrane, thus decreasing the action of the sodium-potassium (Na/K) pump and decreasing Na and water passage to the interstitium.[3]

The method of activation of thiazide diuretics is to cause a change in Na concentration distal to the DCT. Subsequently, ionic channels and pumps work to balance Na levels that have been disrupted. This secondary change to balance Na levels produces many adverse effects. The MOA and its effects on the nephron will be more thoroughly discussed below and will be referred to in the adverse effects section.

Blockage of the Na/Cl channel causes an increase in sodium and water retention in the lumen and a decrease in Na in the DCT.  At the same time, blockage of the Na/Cl channel increases the flow of ions through the Na/Ca channel resulting in increased calcium reabsorption into the interstitium in exchange for Na return to the DCT.

Inhibition of the Na/Cl channel in the proximal segment of the distal convoluted tubule results in an increased delivery of sodium to the distal segment of the distal convoluted tubule and collecting tubule. This increase in Na increase causes the aldosterone-sensitive Na/K pump to increase sodium reabsorption in the principal cells. This exchange increases Na transfer into the interstitium and increases K transfer into the collecting tubules and lumen. This loss of K then causes intercalated cells in the collecting tubule (CT) to increase K reabsorption via the K/H+ pump and is also aldosterone-mediated.

Through aldosterone-mediated sodium retention that is precipitated by an increased Na flow to the CT, the CT will exhibit increase reabsorption of Na and excretion of both K and H ions into the urine.[4]

Administration

Thiazide diuretics are administered orally as tablets. They should be taken in the morning with food. HCTZ and chlorthalidone have different dosing requirements for their indicated FDA uses listed above. Generally, for hypertension treatment, both drugs require a lower dosage starting at 25 mg daily and may be increased to 50 mg or 100 mg, respectively. The dosage should be increased based on the individual therapeutic needs of the patient. For patients suffering from fluid buildup and edema, dosing is started at 50 mg to 100 mg and 50 mg to 200 mg, respectively.[5][6][7][5]

Adverse Effects

Adverse effects of thiazide diuretics stem from the ionic imbalance caused due to the initial Na loss in the DCT.

  • Hypokalemia. Most widely recognized, the first adverse effect of thiazide diuretics is hypokalemia. As discussed above, hypokalemia is a sequelae of the aldosterone-mediated actions of the Na/K pump in the CT. Hypokalemia can be life-threatening and must be monitored during the first 2-3 weeks of HCTZ therapy.
  • Hyponatremia. The MOA of thiazide diuretics is to decrease sodium reabsorption and therefore decreased fluid reabsorption. This directly causes decreased levels of circulating sodium. If hyponatremia were to occur, it would happen during the first 2 to 3 weeks of therapy; after this time the patient is in a new steady state in which further sodium and water losses do not occur.
  • Metabolic alkalosis. Patients on thiazide diuretics may experience a hypokalemic metabolic acidosis due to the increase in aldosterone-mediated K and H ions excretion in the intercalated cells of the CT.
  • Hypercalcemia. Thiazides, through increasing calcium reabsorption from the luminal membrane into the interstitium in exchange for sodium, reduce urine calcium levels and increase blood calcium. However, if indicated this effect of thiazide diuretics allows thiazides to be used for nephrolithiasis and osteoporosis treatment. Decreased urinary calcium decreases stone development in the kidney and increased blood calcium is beneficial for patients with osteoporosis and promotes bone health.
  • Hyperglycemia. Thiazide diuretics cause hypokalemia; at the level of the pancreatic B cells this hypokalemia causes hyperpolarization of the B cell and decreases insulin secretion. Decreased K in the interstitium keeps the K channels open for an extended time, which causes the hyperpolarization of the cell. This hyperpolarization does not allow the voltage-gated calcium channels to open. When intracellular calcium is not increased through calcium influx via the voltage-gated calcium channels, exocytosis of insulin granules does not occur in the pancreatic B cells.
  • Hyperuricemia. Thiazide diuretics cause hyperuricemia and increase the risk of developing gout. Thiazides directly increase urate reabsorption in the proximal tubule by using the OAT 1 anion exchanger on the basolateral membrane and the OAT 4 urate anion exchanger on the luminal membrane. At the OAT 1 exchanger, thiazides enter the proximal convoluted tubule, in replacement of urate, for an anion, increasing urate in the interstitium. At the OAT 4 exchanger, thiazides are exchanged for urate in the lumen. This causes increased urate in the proximal convoluted tubule that then crosses the basolateral membrane and therefore increases urate in the interstitium.
  • Hyperlipidemia. The mechanism of hyperlipidemia with thiazide treatment is unclear. However, it is thought to be an acute response to high dose thiazide treatment.
  • Sulfonamide allergy. Thiazide diuretics are sulfa-containing drugs. Patients with sulfa allergies taking thiazides may experience headache, rash, hives, swelling of the mouth and lips, wheezing or trouble breathing, asthma attack, and anaphylaxis.

Adverse effects of taking these medications also include a possible increased risk of developing acute pancreatitis. It is hypothesized that thiazides have a toxic effect on the pancreas and cause increased pancreatic secretions and pancreatic ischemia. If symptoms of acute pancreatitis are observed the patient must immediately stop use of the thiazide diuretic and they should not be re-prescribed this medication by their physician.[8][9][10]

Contraindications

Thiazide diuretics are contraindicated for use in patients with anuria and sulfonamide allergies.

Enhancing Healthcare Team Outcomes

An Evidence-based Approach to Thiazide Diuretics

Besides physicians, the use of thiazide diuretics is also monitored by pharmacists and nurses. In most cases, thiazide is prescribed for long periods, and hence, patient electrolyte levels need to be monitored. In addition, polypharmacy must be avoided, especially in the elderly. Patients need to be educated on the adverse effects of these agents and their presentation. For those patients with heart problems and susceptibility to arrhythmias, the levels of potassium must be closely followed. Also, the patient needs to be weighed at each visit to ensure that the fluid overload is resolving. Patients prone to hypokalemia must be educated on the consumption of foods that are rich in potassium. Finally, the patient's lipid levels need to be followed as thiazides have been known to cause hyperlipidemia.[11][12] (Level V) 

Outcomes

Thiazide diuretics have been in use for over half a century and are relatively safe and effective drugs for the treatment of hypertension and heart failure. These drugs are used in outpatients to manage chronic edema states. The majority of patients do respond to these agents, and the most common adverse effect reported is hypokalemia. To date, only a few reports of arrhythmias have been reported in patients taking thiazides.[13][14] (Level V)


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Thiazide Diuretics - Questions

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Which is not associated with thiazide diuretics?



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Which of the following does not increase secondary to thiazide diuretics?



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What is the most frequent side effect of thiazide diuretics?



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Which of the following is not associated with thiazides?



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Potassium supplements are often required with which drug?



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Which of the following about thiazide diuretics is false?



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Which condition is a relative contraindication to thiazide diuretics?



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Which of the following is not a complication of thiazide diuretics?



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Hydrochlorothiazide can result in which of the following?



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Which of the following can result from chronic use of hydrochlorothiazide (HCTZ)?



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Hydrochlorothiazide does not cause which of the following?



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Which of the following is not associated with use of thiazide diuretics?



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Which of the following electrolyte disturbances is NOT caused by hydrochlorothiazide?



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A patient presents complaining of pain in her right great toe. She was recently diagnosed with hypertension and started on medication. What medication was most likely started?



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Which of the following electrolyte abnormalities is rarely seen in patients taking thiazide diuretics?



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A 70 year old male is started on medication for hypertension. At the three week follow up blood pressure and heart rate are normal. Laboratories initially were normal but repeat sodium is 131 meq/L. Select which medication was most likely prescribed.



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Which is most likely to be found in a patient receiving a thiazide diuretic?



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Which of the following is not associated with the use of thiazide diuretics?



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A patient with chronic hyponatremia is to be given a diuretic. Which diuretic should be avoided?



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Thiazide Diuretics - References

References

Roush GC,Abdelfattah R,Song S,Ernst ME,Sica DA,Kostis JB, Hydrochlorothiazide vs chlorthalidone, indapamide, and potassium-sparing/hydrochlorothiazide diuretics for reducing left ventricular hypertrophy: A systematic review and meta-analysis. Journal of clinical hypertension (Greenwich, Conn.). 2018 Sep 24     [PubMed]
Riley M,Hernandez AK,Kuznia AL, High Blood Pressure in Children and Adolescents. American family physician. 2018 Oct 15     [PubMed]
Alon US, The Effects of Diuretics on Mineral and Bone Metabolism. Pediatric endocrinology reviews : PER. 2018 Mar     [PubMed]
Pourafshar N,Alshahrani S,Karimi A,Soleimani M, Thiazide Therapy in Chronic Kidney Disease: Renal and Extra Renal Targets. Current drug metabolism. 2018 Jul 1     [PubMed]
Webster R,Salam A,de Silva HA,Selak V,Stepien S,Rajapakse S,Amarasekara S,Amarasena N,Billot L,de Silva AP,Fernando M,Guggilla R,Jan S,Jayawardena J,Maulik PK,Mendis S,Mendis S,Munasinghe J,Naik N,Prabhakaran D,Ranasinghe G,Thom S,Tisserra N,Senaratne V,Wijekoon S,Wijeyasingam S,Rodgers A,Patel A, Fixed Low-Dose Triple Combination Antihypertensive Medication vs Usual Care for Blood Pressure Control in Patients With Mild to Moderate Hypertension in Sri Lanka: A Randomized Clinical Trial. JAMA. 2018 Aug 14     [PubMed]
Alexander RT,McArthur E,Jandoc R,Welk B,Fuster DG,Garg AX,Quinn RR, Thiazide Diuretic Dose and Risk of Kidney Stones in Older Adults: A Retrospective Cohort Study. Canadian journal of kidney health and disease. 2018     [PubMed]
Islam MS, The Art and Science of Using Diuretics in the Treatment of Heart Failure in Diverse Clinical Settings. Advances in experimental medicine and biology. 2018     [PubMed]
Kieboom BCT,Zietse R,Ikram MA,Hoorn EJ,Stricker BH, Thiazide but not loop diuretics is associated with hypomagnesaemia in the general population. Pharmacoepidemiology and drug safety. 2018 Aug 10     [PubMed]
Raffin EP,Penniston KL,Antonelli JA,Viprakasit DP,Averch TD,Bird VG,Chew BH,Sivalingam S,Sur RL,Nakada SY,Pais VM Jr, The Effect of Thiazide and Potassium Citrate Use on the Health Related Quality of Life of Patients with Urolithiasis. The Journal of urology. 2018 Jun 18     [PubMed]
Belai N,Gebrehiwet S,Fitsum Y,Russom M, Hydrochlorothiazide and risk of hearing disorder: a case series. Journal of medical case reports. 2018 May 20     [PubMed]
Nadal J,Channavajjhala SK,Jia W,Clayton J,Hall IP,Glover M, Clinical and Molecular Features of Thiazide-Induced Hyponatremia. Current hypertension reports. 2018 Apr 10     [PubMed]
Reboussin DM,Allen NB,Griswold ME,Guallar E,Hong Y,Lackland DT,Miller EPR 3rd,Polonsky T,Thompson-Paul AM,Vupputuri S, Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2018 May 15     [PubMed]
Verbrugge FH, Editor's Choice-Diuretic resistance in acute heart failure. European heart journal. Acute cardiovascular care. 2018 Jun     [PubMed]
Arroll B,Wallace H, Should we switch from bendrofluazide to chlorthalidone as the initial treatment for hypertension? A review of the available medication. Journal of primary health care. 2017 Jun     [PubMed]

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